GW1-2022-01456_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
I.Well Contractor Information:
CHAD HARTNESS Z -
' 5_- �9 �a" ;14.WATER ZONES .
Well Contractor Name , FROM TO DESCRH'TION
2901 A I A4� 20? E
rr 410 ft.
NC Well Contractor Certification Number J + ft FL
15.OUTER CASING for roulti�ased wells OR LINER ifs licable
AIR DRILLING INC :w�l, Cr t rl� FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft, 122 ft- 6 in. PVC
331655 16.INNER CASING OR TUBING eathermal closed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): to ft. in.
Water Supply Well: 17.SCREEN'
❑A Cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ItResidential Water Supply(single)
in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ft, ft.
18.GROUT
❑Irrl 8ti0n ❑WCIIS>I00,000GPD .FROM TO MATERIAL EMPLACEMENT M UNT
ETHOD&AMO
Non-Water Supply Well: 0 ft- 20 ft• GROUT: POURED
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation fL
❑Salinity Barrier ND/GR
ft.
❑Aquifer Storage and Recovery19.SAAVEL PACK ifa licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fa ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING:LOG attach additional sheets if necesse '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I
FROM To DESCRIPTION color,bardness soiltrock type,grain size,etc.
0 It" 112 ft- DIRT
4.Date We11(s)Completed: 11-10-2021 Well ID# fr ft.
112 425 ROCK
So.Well Location: fa -ft.
DENIS DMITRIYEU ft. ft.
Facility/Owner Name Facility ID€!(ifappliceble) fL ft.
170 GLENN ALLAN RD,MOCKSVILLE,N.C..27028 ft. ft
Physical Address,City,and Zip ft. ft.
DAVIE 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) a ifica n:
350 58.162 N 800 28.370 ----T- -=�-
W -11/10/2021
6.ls(are)the well(s): InPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the tvell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.0100 or 15A NCAC 01C 0200 Well Construction Standards and that a copy
If this•is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).YoVinay also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 425 (ft)
I:or multiple wells list all depths ifdfferent(aratnple-3 a 00'and 2Q100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If waler level is above casing,use"a." Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 246. For Injectiop Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water SuDDIv and OrI Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100 000 GPD•Copy to DWR,CCPCUA
139.Yield(gpm) 10 Method of test: AIR Permit Program,1611 MSC,Raleigh,,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018